Provider Demographics
NPI:1134419013
Name:ENNIN, KWAME BINFO (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KWAME
Middle Name:BINFO
Last Name:ENNIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6047 TICKET WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-6138
Mailing Address - Country:US
Mailing Address - Phone:703-499-2373
Mailing Address - Fax:
Practice Address - Street 1:1840 TAPPAHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560
Practice Address - Country:US
Practice Address - Phone:804-443-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist